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Request assistance.

Complete this form to begin the intake process. Our team will review your inquiry and follow up to discuss your needs and next steps. All information is kept confidential.

In crisis? Call or text 988 for immediate mental health support, or call 911 for emergencies.

About you

First name *

Last name *

Phone *

Date of birth

City

Referral information

How did you hear about us?

Referring person / organization

Referral contact phone

Areas of support needed

Select all that apply

Your situation

Briefly describe your current situation *

What are your goals?

Anything else we should know?

I consent to Second First Steps contacting me about my inquiry and storing my information for intake purposes. I understand this form does not guarantee enrollment in any program. *

All information is kept confidential. Second First Steps does not share personal information without consent.